Abstract

There has been continued interest in the extent to which women have
positive and negative reactions to abortion.

Aims

To document emotional reactions to abortion, and to examine the links
between reactions to abortion and subsequent mental health outcomes.

Method

Data were gathered on the pregnancy and mental health history of a birth
cohort of over 500 women studied to the age of 30.

Results

Abortion was associated with high rates of both positive and negative
emotional reactions; however, nearly 90% of respondents believed that the
abortion was the right decision. Analyses showed that the number of negative
responses to the abortion was associated with increased levels of subsequent
mental health disorders (P<0.05). Further analyses suggested that,
after adjustment for confounding, those having an abortion and reporting
negative reactions had rates of mental health disorders that were
approximately 1.4–1.8 times higher than those not having an
abortion.

Conclusions

Abortion was associated with both positive and negative emotional
reactions. The extent of negative emotional reactions appeared to modify the
links between abortion and subsequent mental health problems.

In a previous
paper1 we examined
the links between the outcomes of pregnancy (including pregnancy loss,
abortion and unwanted pregnancy coming to term) and mental health in a birth
cohort of New Zealand women studied to the age of 30. That analysis showed
that although exposure to abortion was associated with a modest increase in
the risks of mental health problems (relative risk (RR) = 1.3 approximately),
there was no consistent association between other pregnancy outcomes and
mental health. These findings persisted after extensive control for
prospective and concurrent covariates and were found for a range of models
using varying lag assumptions. These findings clearly suggested that unwanted
pregnancy leading to abortion was likely to be a risk factor for subsequent
mental health problems, whereas unwanted pregnancy leading to live birth was
not a risk factor for these problems.

Recently there have been two major US-based reviews of the evidence on the
links between abortion and mental health. Both of these reviews have concluded
that evidence from better-quality studies does not support the view that
abortion is associated with increased risks of mental health
problems.2,3
However, both reviews contained a major flaw that has limited both the
generality and utility of their conclusions. This flaw centres around a
failure to distinguish between two closely related questions about the causal
effects of abortion on mental health. The first question focuses on whether
unwanted pregnancy terminated by abortion is an adverse life event that leads
to increased risks of mental health problems in women exposed to that event.
Addressing this question requires comparing women exposed to abortion with an
equivalent group of women not exposed to abortion. Answering this question is
important for understanding the extent to which the termination of unwanted
pregnancy may be associated with adverse mental health consequences. The
second causal question concerns the issue of whether any adverse consequences
of unwanted pregnancy terminated by abortion are greater or lesser than the
adverse consequences of unwanted pregnancy coming to term. Addressing this
question requires comparing the outcomes of women having abortions with the
outcomes of an equivalent group of women coming to term with unwanted
pregnancies. Answering this question is important for understanding the extent
to which abortion may exacerbate or mitigate any mental health risks
associated with unwanted pregnancy. Both US reviews committed the error of
dismissing large amounts of evidence that was relevant to answering the first
question on the grounds that these data failed to address the second
question.

The present paper reports an extension of our previous
study.1 Here we view
unwanted pregnancy terminated by abortion as an adverse life event that is
potentially associated with increased risks of mental health problems. From
this perspective, an important question concerns the extent to which the
woman’s reactions to abortion may modify risks of mental health
problems. In particular, it would be expected that if unwanted pregnancy
terminated by abortion is an adverse life event that provokes mental health
problems, this association would be influenced by the extent to which the
women perceived the abortion as causing distress, threat or guilt. More
specifically, it would be hypothesised that any adverse mental health effects
of unwanted pregnancy terminated by abortion will be confined to those women
who report significant distress about the abortion.

There have been a number of studies that have examined women’s
reactions to abortion. In general, these studies have found that women report
relatively high rates of both positive and negative reactions to
abortion.4–14
For example, Kero et al found that over 80% of women reported at
least one negative response, with just over two-thirds reporting a positive
response.7 The
majority (52%) of respondents reported a mixture of positive and negative
responses. These findings clearly suggest considerable variation in the
reactions of women to abortion.

Although responses to abortion have been well documented, few studies have
examined the links between reactions to abortion and subsequent mental health.
However, Major and colleagues, using a sample of over 800 women who had
undergone an abortion, found correlations ranging from 0.25 to 0.40 between
participants’ extent of abortion-related distress and subsequent mental
health problems.4
Against this background, the present paper reports on: the frequency of
positive and negative reactions to abortion assessed by retrospective reports
gathered at age 30; the relationships between reported reactions to abortion
and subsequent mental health; and a re-analysis of our previous data to
examine the extent to which reactions to abortion modified the links between
abortion and later mental health disorders.

Method

The data used in this analysis were gathered over the course of the
Christchurch Health and Development Study (CHDS). The CHDS is a longitudinal
study of a birth cohort of 1265 children born in the Christchurch (New
Zealand) urban region who have been studied at birth, 4 months, 1 year and at
annual intervals to age 16 years, and again at ages 18, 21, 25 and 30. The
present analysis is based on the cohort of female participants for whom
information on pregnancy history and mental health outcomes was available. All
data were collected only on the basis of signed consent from research
participants. The study had ethical approval from the Canterbury Ethics
Committee.

Pregnancy and abortion history

At each assessment from age 15 to 30 years, participants were questioned
about any pregnancies occurring since the previous assessment, and the timing
and outcome of each reported pregnancy was recorded. In addition, at age 30
only, participants were asked to provide a summary of their full pregnancy
history. This summary provided information on pregnancy timing, number of
pregnancies and pregnancy outcomes (as a check on prospective data). A further
aspect of the age 30 pregnancy history summary was that participants were also
questioned about whether each pregnancy was wanted or unwanted, and their
initial reaction to the pregnancy at the time. Initial reactions were coded on
a five-point scale from very happy to very unhappy/distressed.

As described in a previous
paper,1 the combined
retrospective and prospective report data were used to define a series of
summary measures reflecting the woman’s pregnancy history for any given
period of interest. Specifically, the information on timing and outcome for
each reported pregnancy was used to classify women on four measures of
pregnancy outcome in any given interval: whether the woman reported having an
elective abortion during the interval; whether the woman experienced a
pregnancy loss (miscarriage, stillbirth, and termination of ectopic pregnancy)
during the interval; whether the woman had a live birth during the interval
for which she reported an unwanted or adverse reaction to the pregnancy; and
whether the woman had a live birth during the interval with no adverse
reaction to the pregnancy. Based on the combined report data, 284 women (53%
of the cohort) reported a total of 686 pregnancies before age 30 including:
153 abortions (occurring to 117 women), 138 pregnancy losses (to 95 women), 66
live births (to 52 women) following an unwanted/adverse reaction to the
pregnancy, and 329 other live births (to 197 women).

Of the 117 women who reported an abortion, 79 (68%) provided consistent
prospective and retrospective reports; 25 (21%) reported an abortion
retrospectively but not prospectively; and 13 (11%) reported an abortion
prospectively but not retrospectively. The overall kappa between prospective
and retrospective reports of abortion was 0.76, suggesting an acceptable level
of reporting reliability. Comparison of the mental heath histories of those
consistently reporting abortion with those giving inconsistent reports showed
no significant differences in the overall rates of mental health problems in
these groups.

Reactions to abortion

As part of the assessment at age 30 years, women who had had an induced
abortion were questioned about their reactions to abortion. Women who had
experienced more than one abortion were asked to respond about their reactions
to their first abortion. Participants were asked about the extent to which
they experienced any of a series of nine emotional responses immediately
following their abortion. These responses included both positive (relief,
happiness, satisfaction) and negative (sorrow, sadness, guilt, regret,
grief/loss, disappointment) responses. Questioning was based on the measures
used by Major et
al4 and Broen
et al.5
Items were coded on a three-point scale reflecting the extent of response (not
at all, somewhat, very much). Participants were also asked how they felt in
hindsight about their decision to have a termination, again based on the
measure used by Major et
al.4 Responses
were made on a three-point scale: definitely the wrong decision; not sure;
definitely the right decision.

Mental health

At each assessment from age 16 to 30 years, participants were questioned
about mental health issues since the previous assessment using structured
questionnaires based on the Diagnostic Interview Schedule for Children
(DISC)15 at age 16
years and the Composite International Diagnostic Interview
(CIDI)16 at ages
18–30 years, supplemented by additional measures. From this questioning
it was possible to ascertain the proportion of young women who met
DSM–IV17
diagnostic criteria for the following disorders during the intervals
15–18, 18–21, 21–25 and 25–30 years: major depression;
anxiety disorders (including generalised anxiety, panic disorder, agoraphobia,
social phobia and specific phobia); alcohol dependence; and illicit drug
dependence. In addition, measures of DSM–IV disorders were supplemented
by measures of self-reported suicidal ideation. To provide an overall measure
of the burden of mental disorder, the five individual measures were summed to
obtain a count of the number of mental health problems reported for each
interval. This count measure was the primary outcome used in the present
analysis.

Covariate factors

A wide range of factors were considered for inclusion as covariates in the
analysis. A full description of these covariates has been provided in a
previous paper1 and
only a summary listing is given here. The factors were selected from the study
database on the basis that they were correlated with either the measures of
pregnancy history or mental health outcomes and spanned the following
domains.

Measures of childhood socioeconomic circumstances including parental
education levels, family socioeconomic status, family living standards and
family income.

Measures of adolescent adjustment including early onset sexual intercourse
(<16 years), early substance use (tobacco, alcohol and cannabis at age 15),
and adolescent mental health problems (depression, anxiety, suicidal
ideation).

Time dynamic lifestyle and other factors including: living arrangements in
young adulthood (living with parents, cohabitations, age of leaving the family
home); and measures of exposure to adverse life events (employment problems,
partner relationship problems, serious illness or death in the family, sexual
or physical violence victimisation, history of pregnancy loss) in each
assessment interval. In addition, to control for the changing history of prior
mental health, a lagged measure of the number of mental health problems
observed in the previous assessment period was also considered.

Statistical analysis

Reactions to abortion

Tables 1 and
2 report on the frequency of
negative reactions to abortion, positive reactions to abortion, and assessment
of the overall abortion decision.

Negative reactions to abortion and mental health

Table 3 examines the
relationship between the number of definite negative reactions to abortion
classified into three groups (no problems, one to three problems, four to six
problems) and rates of mental health problems (depression, anxiety disorder,
suicidal ideation, alcohol dependence, illicit drug dependence and total
number of problems) over the period from 15 to 30 years. The estimates in this
table were obtained by pooling the data over the four assessment periods
(15–18, 18–21, 21–25, 25–30 years) to obtain
population averaged estimates of the rates of disorder for each level of
abortion-related distress. The association between abortion-related distress
and total number of mental health problems was modelled by fitting a repeated
measures random effects Poisson regression model to data on: the number of
mental health problems reported within a given assessment period (15–18,
18–21, 21–25, 25–30 years); and the number of negative
emotional reactions experienced by women who had had an abortion by the end of
the assessment period. The fitted model was:
(1)
where log(Yit) was the log rate of mental health
problems (Y) for the i-th individual in the t-th
time interval; Xi was the number of negative reactions to
abortion reported by the i-th participant (scored as: 0, no distress;
1, one to three problems; 2, four to six problems); νi
was an individual specific random effect assumed to be uncorrelated with
Xi; and eit was the
disturbance term for the model. The intercept B0 was permitted to
vary with time t to allow for changes in the base rate of mental
health problems over time. The effect of number of negative reactions to
abortion was assumed to be linear with coefficient B1.
Table 3 reports on the pooled
rates of mental health problems for each level of negative reactions and
provides estimates of the incidence rate ratio (IRR) and corresponding 95% CI
for each group based on the linear model in Equation 1. The IRR for a one-unit
step on the number of negative reactions measure was obtained from the fitted
coefficient B1 and its standard error in the usual way
eB1±1.96s.e.(B1).

Abortion and subsequent mental health

The final stage of the analysis examined the relationship between exposure
to abortion (classified as: no abortion; abortion with no definite adverse
reaction; abortion with one to three definite adverse reactions; abortion with
four to six definite adverse reactions) and rates of mental health problems
for all female cohort members over the period from 15 to 30 years. This
analysis was based on an extension of the analysis reported in a previous
paper.1 Following
this paper two modelling approaches were used.

Concurrent model. In this model the respondent’s history of reaction
to abortion by the end of a given observation interval was related to mental
health outcomes within that interval (15–18, 18–21, 21–25,
25–30 years). The fitted model was:
(2)
where was a time
dynamic dichotomous variable reflecting whether the i-th participant
had an abortion by t-th time interval;
was a continuous
variable reflecting the extent of abortion-related distress as in Equation 1
with women who did not have an abortion scored as 0;
X2it, X3it,
X4it were time dynamic dichotomous measures
reflecting exposure of the i-th participant to pregnancy loss
(miscarriage, stillbirth or ectopic pregnancy), live birth resulting from an
unwanted/adverse reaction to pregnancy, or other live birth respectively;
Zij and Zikt were
sets of fixed and time dynamic covariates respectively; νi was
an individual specific random effect and eit was
the disturbance term for the model.

A 5-year lagged model. In this model a strict temporal sequence was imposed
on the data so that the assessment of abortion and pregnancy outcomes was
restricted to those pregnancies that occurred in the 5-year period prior to
the assessment of the mental health outcomes. The specification for this model
was similar to the specification of the model in Equation 2 except that the
measures of pregnancy/abortion outcomes and time dynamic covariates were
lagged in the 5 years preceding the intervals in which mental health outcomes
were assessed.

Table 4 shows the IRRs and
corresponding 95% CIs estimated using combinations of the parameters
Ba1, Bb1 for
both models. Estimates of the unadjusted IRRs were also obtained by fitting
models that excluded all other predictors from the model except for the
measures of abortion. In each case a test of the effect of abortion
exposure/abortion-related distress was given by a Wald chi-squared test of the
joint null hypothesis H0:
Ba1 = 0; Bb1 =
0. These analyses were restricted to an examination of the total number of
mental health problems reported in each interval since attempts to analyse
individual diagnoses (depression, anxiety disorder, suicidal ideation, alcohol
dependence, illicit drug dependence) proved to be unsatisfactory owing to
problems relating to sparse cell sizes, inflated standard errors and unstable
parameter estimates. For these reasons no clear conclusions can be drawn about
the links between reactions to abortion and specific mental health outcomes.
All models were fitted using Stata version 10 for Windows.

Associations between abortion history (subdivided by degree of
abortion-related distress) and rates of mental health problems (15–30
years) before and after adjustment for covariates (n = 532)

Sample sizes

The analysis of initial reactions to abortion was based on a sample of 104
women who had experienced an induced abortion and who were interviewed at age
30. This sample represented 89% of all those women (n = 117)
reporting an abortion by age 30. The analysis of the associations between
abortion/pregnancy history and rates of mental health problems was based on a
sample of 532 women with data available on abortion history and mental health
outcomes for at least one assessment period from 15 to 30 years. This sample
represented 84% of the initial cohort of 630 females. As described in a
previous paper,1
data weighting methods were used to examine the extent to which the pattern of
missing data may have influenced study conclusions. This analysis produced
almost identical conclusions to the results reported here, suggesting that the
findings were unlikely to have been influenced by selection bias.

Results

Reported reactions to abortion

Tables 1 and
2 describe women’s
reaction to abortion as reported at age 30.
Table 1 reports on negative and
positive reactions to abortion, and Table
2 reports on the woman’s overall assessment at age 30 of the
appropriateness of the abortion decision.

In Table 1, the section on
negative reactions suggests that the majority of women reported at least one
negative emotional reaction, including: sorrow, sadness, guilt, regret, grief,
and disappointment. Over 85% of the group mentioned at least one of these,
with 34.6% reporting five or more negative reactions. In terms of definite
reactions to the abortion in which the woman reported that she had experienced
the reaction ‘very much’, over 55% of the sample reported at least
one definite reaction, with 34.6% reporting thee or more such reactions. These
results clearly suggest that there was a spectrum of negative reaction ranging
from a minority of women who reported no negative response, to a group who
reported several definite negative reactions.

In part, the high frequency of negative reactions was offset by a number of
positive reactions, including: relief, happiness, and satisfaction. Over 86%
of women reported at least one positive reaction, with 29.8% reporting all
three reactions. In terms of definite reactions, 59.6% reported one or more
definite reactions, with 12.5% reporting three definite positive
reactions.

The findings suggest that many women experienced a mixture of both positive
and negative emotions about having an abortion. These findings raise the issue
of the extent to which the decision to have an abortion was seen to be
correct. As may be seen from Table
2, nearly 90% of women questioned at age 30 thought the decision
was correct, and only 2% believed it to be incorrect.

In general, the findings in Tables
1 and
2 suggest that although women
experienced a mix of positive and negative emotions about having an abortion,
an overwhelming majority reported that they believed they had made the right
decision in having an abortion.

Negative reactions to abortion and subsequent mental health

The findings in Tables 1 and
2 raise the important issue of
the extent to which reactions to abortion were prognostic of mental health
outcomes after abortion. Table
3 shows the associations between the extent of distress reported
by the women subsequent to abortion and rates of mental health problems
(depression, anxiety, suicidal ideation, alcohol dependence, illicit drug
dependence, total number of mental health problems). Distress was measured
using a count of the number of items in
Table 1 to which the women made
a definite negative response, classified into three levels (no negative
reactions, one to three negative reactions, four to six negative reactions).
As explained in the Method, rates of mental health problems have been pooled
over all observation periods (ages 15–18, 18–21, 21–25,
25–30 years) to produce population-averaged rate estimates for each
outcome, and rates have been reported using both concurrent and 5-year lagged
models for the assessment of the timing of abortion.
Table 3 also reports the
estimated IRR and corresponding 95% CI for the total number of mental health
problems for each level of distress relative to those who reported no adverse
reactions to abortion.

For the concurrent model, increasing abortion-related distress was
associated with increasing rates of mental health problems. These trends were
most evident for major depression, anxiety disorder and suicidal behaviour,
and least evident for alcohol dependence and illicit drug dependence. A random
effects model fitted to the overall rates of mental health problems showed a
significant linear association (P = 0.04) with the extent of reported
distress. Overall, women reporting four or more distress responses had rates
of mental health problems that were approximately 1.5 times higher than those
of women not reporting distress.

The 5-year lagged model showed that risks of all disorders tended to
increase with increasing symptoms of distress. A random effects model fitted
to the overall rates of mental health problems also showed a significant
linear association (P = 0.047) with the extent of reported distress.
Overall, women reporting four or more distress responses had rates of mental
health problems that were also 1.5 times higher than for women exposed to
abortion who did not report distress.

A parallel analysis using the number of positive responses to abortion
failed to show any association between the number of positive responses and
rates of mental health problems. The findings in
Table 3 clearly suggest that
increasing distress associated with abortion was associated with increased
risks of mental health problems.

Distress as a moderating factor

A previous paper1
showed that even following extensive control for confounding factors, exposure
to abortion was associated with moderate increases in rates of mental health
problems (with IRRs of approximately 1.3). The findings in
Table 3 raise the clear
possibility that the association between abortion and mental health outcomes
may be modified by the degree of distress associated with the abortion. To
examine this issue, the previous analysis of the association between overall
rates of mental health problems and abortion was extended to incorporate the
extent of reported distress associated with abortion by classifying those
having an abortion into the three groups shown in
Table 3: those reporting no
definite adverse response; those reporting one to three definite negative
reactions; and those reporting four to six definite negative reactions. The
results of this re-analysis are presented in
Table 4, which summarises the
results for the two modelling methods – concurrent and 5-year lagged
analysis (see Method for an account of these models). These models were based
on data for 532 women observed during the period 15–30 years.

For each model, Table 4
reports: the unadjusted associations between abortion history (subdivided by
degree of abortion-related distress) and overall rates of mental health
problems; and the covariate adjusted associations. In each case, the
associations are summarised by the IRRs and corresponding 95% CIs for the rate
of mental health problems for each level of abortion-related distress relative
to those not exposed to abortion. The adjusted analysis considered a wide
range of covariates based on our previous
analysis.1 These
covariates included measures of: childhood socioeconomic circumstances;
childhood family functioning; parental adjustment; exposure to abuse in
childhood; individual characteristics; educational achievement; adolescent
adjustment; other pregnancy outcomes (e.g. pregnancy loss, live birth); and
other time dynamic lifestyle and related factors (see Method).
Table 4 also lists the
significant covariates for each model.

Unadjusted results

For both models there was clear evidence of a relationship in which rates
of mental health problems increased significantly (P<0.001) with
increasing abortion-related distress. Both models suggest that those having
abortions but not reporting definite distress had rates of mental health
problems that were approximately 1.3 times higher than for those not having an
abortion; those having an abortion and reporting one to three definite
negative reactions had rates that were approximately 1.6 times higher; and
those having an abortion and reporting four to six definite negative reactions
had rates that were approximately 1.9–2.0 times higher than for those
not having an abortion. For the concurrent model, rates of mental health
problems were significantly higher at all levels of distress than for those
not having an abortion, whereas for the 5-year lagged model rates were
significantly higher only among those who reported definite negative reactions
to abortion.

Adjusted results

For both models, adjustment for confounding factors tended to reduce the
size of the associations but clear and significant (P<0.001)
relationships remained between the extent of distress associated with abortion
and rates of mental health problems. Specifically, after adjustment for
covariates the association between abortion with no negative reactions and
mental health problems became non-significant for both models, with risk
ratios ranging from 1.14 to 1.24; whereas those reporting distress had
significantly higher rates of mental health problems, with these rates
increasing with the extent of distress. The net effect of these trends was
that those exposed to abortion and reporting four or more definite negative
reactions had adjusted rates of mental health problems that were between 1.64
and 1.81 times higher than for those not exposed to abortion
(P<0.01).

More generally, the results from both models suggested that the
relationship between unwanted pregnancy terminated by abortion and mental
health depended critically on the extent to which abortion was associated with
distress and that any increase in risks of mental health problems in women
exposed to abortion was largely confined to those women who reported one or
more definite symptoms of distress.

Discussion

In this study we have examined the extent to which the association between
abortion and mental health found in a previous
study1 was modified
by the woman’s reactions to the abortion. The key findings of this study
are summarised below.

Reactions to abortion

In agreement with previous research in this
area,4–14
women reported a range of reactions to abortion with a substantial number
reporting feelings of grief, guilt, loss and related emotions in response to
abortion. Over 85% of women reported at least one of these adverse reactions,
with a third reporting five or more of these reactions. However, these
negative reactions to abortion were offset by positive responses including
relief, happiness and satisfaction, with these responses being noted by over
85% of women. Importantly, on the basis of assessments made at age 30, nearly
90% stated that the decision to have an abortion was the correct one, and only
2% reported that they believed the decision to be incorrect. These findings
are consistent with previous research which suggests that the great majority
of women do not regret the decision to have an
abortion,4,6
and the accumulated evidence on this topic does not support recent claims from
pro-life advocates that large numbers of women who have abortions regret their
decision.18

Adverse reactions and mental health outcomes

The second stage of the analysis examined the relationship between the
extent of adverse reaction to the abortion and risks of subsequent mental
health outcomes. This analysis suggested the presence of a clear relationship
in which risks of subsequent mental health problems increased with the extent
of distress, upset or guilt reported by the woman: women reporting four or
more negative reactions had rates of subsequent mental health problems that
were 1.5 times higher than women reporting no distress.

These findings were then incorporated into general multivariate models
aimed at assessing the relationship between the extent of distress to abortion
and subsequent mental health taking into account a wide range of covariate
factors. These analyses confirmed the general conclusions that increasing
reports of abortion-related distress were associated with increasing risks of
mental disorders: women who reported at least one negative reaction to the
abortion had rates of mental health problems that were approximately
1.4–1.8 times higher than women not exposed to abortion, and between 1.2
and 1.6 times higher than women who were exposed to abortion but did not
report any adverse reactions to abortion. All of these findings are consistent
with the conclusion that unwanted pregnancy terminated by abortion is an
adverse life event that increases risks of mental health problems, with these
increases in risk being proportional to the degree of distress associated with
the abortion of an unwanted pregnancy.

The finding that the extent of distress associated with abortion modifies
the risks of subsequent mental health problems is consistent with the view
that it is the woman’s reaction to abortion that increases risks of
mental health rather than the experience of unwanted pregnancy. Our results
suggest that women who have unwanted pregnancy terminated by abortion who do
not experience distress do not show increased risks of mental health problems.
This finding is consistent with the results of our previous study that showed
that unwanted pregnancies that came to term were not associated with a
detectable increase in risks of mental health
problems.1

Combining the findings of our two studies leads to the following
generalisations about the links between unwanted pregnancy, abortion and
mental health in this birth cohort.

First, unwanted pregnancy terminated by abortion was associated with
modestly increased risks of common mental health problems for women who
reported significant distress about the abortion (RR = 1.4–1.8).

Second, unwanted pregnancy terminated by abortion was not associated with
significantly increased risks of mental health problems for women who did not
report significant distress about the abortion (RR = 1.14–1.24).

Third, unwanted pregnancy that came to term was not associated with
significant increases in mental health problems (RR = 1.05–1.11).

Finally, any associations between unwanted pregnancy, abortion and mental
health problems were small to moderate, with adjusted relative risks in the
region of 1.1–1.8. Estimates of the population attributable risk
suggested that exposure to unwanted pregnancy terminated by abortion accounted
for fewer than 5% of the mental health problems experienced by women in this
cohort.1

As we have noted
previously,1 these
findings are not consistent with strong pro-life positions that depict
unwanted pregnancy terminated by abortion as having devastating consequences
for women’s mental
health.19 Equally,
however, the findings do not support strong pro-choice positions that claim
unwanted pregnancy terminated by abortion is without mental health
risks.20 Rather,
the accumulated evidence suggests that unwanted pregnancy terminated by
abortion is an event that leads to significant distress in some women, with
this distress being associated with a modest increase in risk of common mental
health problems.

Limitations

These conclusions need to be interpreted in the light of a number of
potential limitations of the study. The greatest limitation is that the
assessment of abortion-related distress was based on retrospective reports
obtained at the age of 30. Such reports may be subject to errors of
reminiscence and possible recall bias. For this reason it is important that
our findings are replicated using prospective data to assess the links between
abortion distress and subsequent mental health. Although a number of studies
have reported on rates of abortion distress, to date no study appears to have
linked this distress to later mental health outcomes, with the possible
exception of Major et al who reported correlations of 0.25–0.40
between the extent of abortion-related distress and subsequent mental health
problems.4 That
study is consistent with the view that the extent of distress associated with
abortion plays a significant role in determining subsequent mental health
outcomes. It addition, as is the case with all observational studies,
conclusions may be influenced by omitted confounders and errors of measurement
in the assessments of exposure and outcome. Further, the present data are
unclear as to whether negative reactions to abortion were more common among
participants who were members of communities or groups in which an unwanted
pregnancy or abortion may have been viewed most negatively. Nonetheless, the
accumulated evidence is consistent with the major conclusions outlined
above.

Implications

These conclusions have implications for both service provision and the
interpretation of the law in jurisdictions such as New Zealand, and England
and Wales. The finding that the extent of distress caused by the abortion is a
predictor of subsequent mental health suggests the need for providers of
abortion to: conduct thorough screening of abortion-related distress; to carry
out adequate follow-up of those showing distress; and to counsel those showing
distress about future mental health risks and the need for
support.10,21
In terms of legal issues, our findings have important implications for
jurisdictions such as England and Wales, and New Zealand where over 90% of
abortions are authorised on the grounds that proceeding with the unwanted
pregnancy would pose a serious threat to the woman’s mental
health.22,23
There is no evidence in this research that would suggest that unwanted
pregnancies that come to term were associated with increased risks of mental
health problems or that abortion mitigated the risks of mental health problems
in women having unwanted pregnancy.

In addition, although recent reviews of the
evidence2,3
have concluded that abortion is not associated with increased mental health
risks when compared with unwanted pregnancies that come to term, no review to
date has found that abortion is associated with a reduction in mental health
risks. Collectively, this evidence raises important questions about the
practice of justifying termination of pregnancy on the grounds that this
procedure will reduce risks of mental health problems in women having an
unwanted pregnancy. Currently there is no evidence to support the assumptions
underlying this practice, and the findings of the present study suggest that
abortion may, in fact, increase mental health risks among those women who find
seeking and obtaining an abortion a distressing experience.

Funding

This research was funded by grants from the Health Research
Council of New Zealand, the National Child
Health Research Foundation, the Canterbury
Medical Research Foundation and the New Zealand
Lottery Grants Board.